Is prednisone (corticosteroid) used to treat severe eczema (atopic dermatitis)?

Prednisone Use in Severe Eczema

Systemic corticosteroids like prednisone should generally be avoided for treating severe eczema (atopic dermatitis) and should be reserved only for special circumstances due to the risk of rebound flares and adverse events. 1

When Systemic Corticosteroids May Be Considered

Oral corticosteroids may be considered in very limited circumstances:

• As a short-term intervention (<7 days) for severe acute exacerbations when other options have failed 2
• As a bridge to other systemic therapies or phototherapy 3
• In anticipation of a major life event in the most severe cases 3
• When there is an immediate need for relief in very severe cases 3

Preferred Treatment Algorithm for Severe Eczema

First-line Treatments:

• Topical corticosteroids (TCS) of appropriate potency:
  • Medium-potency for body areas
  • Low-potency for face, neck, and intertriginous areas 1
  • Applied once or twice daily (once daily application of potent TCS is as effective as twice daily) 4
• Emollients applied 3-8 times daily, even when skin appears normal 1
• Identification and avoidance of triggers 1

Second-line Treatments:

• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) 2, 1
• Topical PDE-4 inhibitors (crisaborole) 2
• Proactive therapy with TCS 1-2 times weekly to prevent flares after disease stabilization 1, 5

Third-line Treatments (for very severe cases):

1. Phototherapy (narrowband UVB) 2, 1
2. Biologics (dupilumab, tralokinumab) 2, 1
3. JAK inhibitors (upadacitinib, abrocitinib, baricitinib) 2, 1
4. Immunomodulators (cyclosporine, methotrexate, azathioprine, mycophenolate) 2, 1

Evidence Against Routine Prednisone Use

• A double-blind randomized trial comparing prednisolone with cyclosporine for severe eczema was terminated early due to high withdrawal rates in the prednisolone group. Only 1 of 21 patients receiving prednisolone achieved stable remission compared to 6 of 17 patients treated with cyclosporine (p=0.031) 6

• The International Eczema Council consensus statement discourages the routine use of systemic corticosteroids for atopic dermatitis 3

• Rebound flares are common upon discontinuation of oral corticosteroids 2

• Recent evidence suggests that even short-term use of oral corticosteroids is associated with a small but significantly increased risk of severe adverse events in both children and adults 2

Important Caveats and Pitfalls

• Rebound phenomenon: When systemic corticosteroids are discontinued, eczema often returns with greater severity than before treatment 2, 3

• Children: Most experts agree that systemic corticosteroids should never be used in children with eczema 3

• Long-term use: Long-term use of oral corticosteroids is not recommended due to well-known adverse effects including growth suppression, osteoporosis, hypertension, diabetes, and adrenal suppression 2, 1

• Infection risk: Patients with eczema often have Staphylococcus aureus colonization, and systemic corticosteroids may increase infection risk 2

When to Refer to a Specialist

Referral to a dermatologist is recommended in cases of:

• Diagnostic uncertainty
• Failure to respond to appropriate topical treatments
• When second-line or third-line treatments are required
• Severe or widespread disease 1

By following this evidence-based approach, healthcare providers can effectively manage severe eczema while avoiding the pitfalls associated with systemic corticosteroid use.